Mike Luca reviews Judd Kessler's "Lucky by design" in the WSJ

 In the WSJ, Mike Luca has a good book review of Judd Kessler's "Lucky by Design".  

‘Lucky by Design’ Review: The Game of Getting More
Costly signals can help with college admissions and hiring. Visiting a campus or attending a meeting in person demonstrate commitment.  By Michael Luca 

"In “Lucky by Design,” Judd Kessler turns over the cards in often-hidden markets, offering advice on topics from standing out in a job hunt to getting a dinner reservation at an in-demand restaurant. Mr. Kessler, a professor of business economics and public policy at Wharton, notes that these systems frequently “allocate valuable, scarce resources without relying on prices” and that the criteria “are not always obvious or visible the way that prices are.”

Mr. Kessler’s premise is that we can make our own luck by understanding the rules of a system and navigating the process accordingly. Take sign-ups for popular children’s activities such as summer camps or after-school programs, which are often offered on a first-come, first-served basis. Mr. Kessler advises that the key in these situations is to “recognize that you are in a race” and “be there, ready to sprint, when the starting gun goes off.” He suggests reading between the lines: If an email offers a starting time for sign-ups, but no end time, it may be because organizers expect things to go quickly, suggesting it’s time to lace up. 

... 

"What’s good for individuals need not be good for the system overall. Mr. Kessler recounts how, when traveling by plane, he and his wife used to book the aisle and window seats in the same row, hoping the middle seat would remain empty but offering to trade for the aisle seat if someone showed up: a clever hack for one group, but one that would get complicated quickly if everyone did that.

"An overemphasis on winning risks rewarding the vigilant while exhausting everyone. Constant sprinting also risks crowding out time for quiet reflection. Mr. Kessler offers a helpful release valve he calls “settling for silver,” a strategy for stepping away from the fiercest competition. Sometimes the race is unavoidable, and it helps to know the quickest route. But the deeper question isn’t whether to sprint harder or settle sooner; it’s defining for ourselves what the prize is and what will actually bring us joy and fulfillment in life. After all, as Mr. Kessler writes, “the fact that we have different preferences is what makes markets—and life—more exciting.” 

The administration takes its eye off medical journals (TACOs can be good)

The war against science hasn't just focused on research universities, but also on scientific journals. (The concern with journals is that they privilege evidence, which is seen as discriminating against some viewpoints.)  And the war on science has a particular focus on medicine, and hence on medical journals. But policing journals takes patience, and (in this case, fortunately) the eye of Sauron doesn't have a lot of patience. (Sort of like pediatricians, who are always in a hurry because they have little patients...) 

Medpage Today has the story:

DOJ Sent Letters to Medical Journals. Then What Happened?
— Worrying probe into publications' partisanship may have lost steam  by Rachael Robertson, 

"A few months into the second Trump administration, major medical journals received letters from Edward R. Martin Jr., who was the U.S. attorney for the District of Columbia at the time. (He has since been replaced by Jeanine Pirro.) 

"The first letter to come to light was addressed to CHEST Editor-in-Chief Peter Mazzone, MD, MPH, of the Cleveland Clinic, and dated April 14. Martin's letter contained five questions, including how the journal assessed its "responsibilities to protect the public from misinformation" and how it handled competing viewpoints. Martin requested a response by May 2.

"Other major journals received similar letters, including the New England Journal of Medicine and Obstetrics & Gynecology, the official journal of the American College of Obstetricians and Gynecologists, as well as two other journals that did not want to be named.

"But since receiving those letters in April, the publications haven't heard a peep on the matter from DOJ, several of the journals confirmed to MedPage Today. Most of the journals also declined to comment on the details of their responses to DOJ's letter. "

History of the U.S. National Science Foundation (NSF)

 The NSF has played a key role in American science, and risks being collateral damage in the war against science.

Here is a their history web page:

History of the U.S. National Science Foundation 

Like many scientists, I'm deeply grateful for their support, particularly their early support. 

 The section "NSF's history and impacts: A brief timeline" mentions some accomplishments decade by decade, including this for the 2010's

    2010

"NSF-supported researchers use economic matching theory to develop a kidney exchange program that dramatically improves efficiency and doctors' ability to match organs. For his work in this area, Alvin Roth shares the 2012 Nobel Memorial Prize in Economic Sciences."

#####

All my posts on NSF.  

The Economic Experience: An Introduction through Experiments by Charles A. Holt and Erica Sprott

 Princeton University Press has a new economics textbook centered on experiments:

 The Economic Experience: An Introduction through Experiments by Charles A. Holt and Erica Sprott  

"An innovative introduction to economic behavior that uses interactive experiments to promote experience-based discovery"

Here's my blurb:

“Experiments have had a huge impact on behavioral economics, and Holt and Sprott’s book aims to make teaching economics, through experiments, easy on instructors and fun for students.”—Alvin Roth, Stanford University

 

What to read in 2026: FT recommends Moral Economics (plus blurbs by Milgrom, Wilson and Goldin:)

 The Financial Times looks into its crystal ball to suggest what books to read in the coming year, organized by the month in which they are scheduled to appear.  I'm happy to see my book among them. (And the first two blurbs are now online as well:)

What to read in 2026 

May 

    Moral Economics: What Controversial Transactions Reveal About How Markets Work by Alvin Roth (Basic Books)
Today’s fiercest moral battles are reframed as questions of market design, rather than absolute rights and wrongs. From reproductive medicine to drug policy and organ donation, Nobel Prize winner Roth shows how societies can calibrate what is permitted, restricted or banned without abandoning ethical concern.
 

The subtitle (subtly different from the U.S. version) reveals that they are thinking of the U.K. Version of my book. 

 

 

"Review
"From the right to sell a kidney to the cost of a surrogate birth, our sense of "right and wrong" shapes the economy more than we realize. Nobel laureate Alvin Roth - the world's leading "philosopher-economist" -unpacks the hidden moral codes that govern our most intimate transactions. This is a clear-eyed guide to understanding where the market ends, where morality begins, and how we can design a world that honors both -- Paul Milgrom and Robert Wilson, Nobel laureates, Stanford University

"With clarity and compassion, Al Roth explores the transactions society cannot escape - surrogacy, the purchase of body parts, the sale of sex, and a host of "repugnant" relationships. What should be regulated? What should be banned? What are the limits of using price in the marketplace? Be prepared to think in new ways and gain from the insights of a great market designer -- Claudia Goldin, Nobel laureate and author of CAREER AND FAMILY  "

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

The published version of our paper is now widely available:

Kimberly D. Krawiec and Alvin E. Roth, “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood,” in James Stacey Taylor and Mark J. Cherry, eds., Markets in Human Organs for Transplantation: Controversy and Contention., Routledge, November 2025 (open source) https://www.taylorfrancis.com/reader/download/5885e1ba-c9af-4547-941c-821a2afaa7ee/chapter/pdf?context=ubx  

From the introduction:

[The nonremuneration principle] is only half of a WHO policy, broadly accepted around the world, that mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs (hereafter, the “twin principles”) (WHO 2009, 2023). This self-
sufficiency mandate, though less examined than the ban on  remuneration, presents a real hurdle to progress in transplantation, especially for smaller and low and middle income (LMIC) countries. 

"WHO’s insistence on self-sufficiency inhibits cooperative kidney
exchange efforts (as well as other innovations) among countries that
would benefit all concerned, especially the LMIC that the policy is purportedly designed to help. As will be discussed, the policy’s effect on blood products, especially when combined with the no remuneration rule, is even more stark – no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
 

"This chapter critiques these twin principles, making several central points. In Section 2.2, we discuss the twin principles as applied to blood products, noting the particularly pernicious effects on plasma supply and availability, especially in poorer nations. In Section 2.3, we turn to transplantation, emphasizing the numerous benefits of international cooperation and cross-border transplantation – benefits that would be undermined by self-sufficiency, especially in smaller countries and those without well-developed domestic exchange programs. We illustrate this point with examples drawn from several noteworthy instances of cross-border kidney exchange.
 

"In Section 2.4, we argue that the current discourse around remuneration and organ donation is frequently overdramatic and unhelpful. Although nearly every effort to increase organ donation and transplantation presents ethical challenges, not every such effort amounts to “trafficking” or “a crime against humanity.” These labels stifle helpful deliberation, progress, and consensus. Section 2.5 concludes with recommendations for a saner approach to the scarce resources of blood products and transplantable organs – one that is focused on international cooperation, rather than self-sufficiency; evidence-based policies, rather than a reliance on decades-old
assumptions and understandings; and the use of pilot studies and trials to test the ethics, safety, and efficacy of incentives in various settings."

######

Here's the book:

 

Commercial plasma collection in the US: the Jaworski report for 2025

 Peter Jaworski, a tireless student of blood donation around the world, has published a report on the plasma industry.  It's full of interesting facts, a few of which are highlighted below.

America’s Plasma Contribution to the World: 2025
Launching the Georgetown Blood and Plasma Research Group and the annual state of the U.S. plasma industry report  by Peter Jaworski 

"I am proud to announce the official launch of the Georgetown Blood and Plasma Research Group. Housed at Georgetown University, this initiative will serve as a dedicated academic hub for research on the ethics and economics of global supply chains for not only blood plasma, but blood, bone marrow, and other medically-useful substances of human origin. Our goal is to provide data-driven insights, foster serious philosophical discussion, and be a home for interdisciplinary research.
 

"This 2025 Annual Report is the first contribution to that mission. 

...

"As of December 31, there are 1,247 plasma collection centers in the United States (including four centers in Puerto Rico).

"To put this into perspective: The U.S. is now home to more plasma centers than community colleges (just over 1,000) or Kohl’s department stores (around 1,175). There are almost as many plasma collection centers as Denny’s restaurants (around 1,300). 

...

"we can look at the economics of independent plasma companies. Their business is to sell plasma to fractionators, not to make medicine from the plasma.

"The current selling price of a liter of plasma is around $190, give or take $10.

• Donors receive between 30-40% of that revenue, or around $70 (an average donation is 850 - 880 mL, requiring more than one donation to equal a liter).
• The center spends a majority of the remaining revenue on costs like employees, supplies (“softgoods”), testing, and facility overhead.
• The plasma center will pocket around 8-12%, or around $15 in profit. 

...

"The U.S. plasma industry does more than save American lives, it provides the material for life-saving therapies for patients around the world.

"The 62.5 million liters collected in the U.S. in 2025 represents around 68% of global plasma collections for the manufacture of medicines. About 52% of those collections will end up in medicines to treat American patients, while the remaining 48% will end up treating patients in the rest of the world."

John Henry Kagel (1942-2026), an incomparable experimental economist

 John Kagel will be buried this morning,  January 7, at  New Tifereth Israel Cemetery in Columbus, Ohio. He passed away yesterday.  I don't know the details, but my sense is that he hadn't been well for a while. He was 83.

In his prime, John was the best experimental economist in the world.

He was also my friend, colleague, coauthor, co-editor, and all-around mensch and role model. He was full of life.  

Words fail. 

Here's his Google scholar page. 

In 2023 the journal Experimental Economics had a special issue in John's honor: here's the Introduction. 

May his memory be a blessing. 

Surrogacy stories (state regulators, take note)

 Surrogacy in the U.S. has become well established, with commercial surrogacy legal in almost all US states.  But problems sometimes occur, often of a financial nature, which suggest that in many places the regulatory oversight is still insufficient. (It's natural new regulations should be applied to newish markets as they experience fixable problems...)

Here are three recent stories that I recommend to the attention of regulators. 

WSJ:

Surrogacy Is a Multibillion-Dollar Business—but Surrogates Can Be Left With Big Debts
Booming fertility industry, a new target of private-equity and other investors, is largely unregulated, leaving the women giving birth with few financial or legal protections  By  Katherine Long

 

NBC

 How a top-tier surrogacy agency became an FBI target
Dozens of clients and surrogates were left panicked and in the dark after the agency’s owner seemingly disappeared. One intended parent, Mariana Klaveno, is missing $66,000. By Kenzi Abou-Sabe, Alexandra Chaidez, Liz Kreutz and Andrew Blankstein

 

NYT:

A Surrogacy Firm Told Parents-to-Be Their Money Was Safe. Suddenly, It Vanished.
Surro Connections held itself out as a reliable business. Now, clients have lost as much as tens of thousands of dollars meant to compensate women carrying their pregnancies.  
By Sarah Kliff

Prenups: formerly repugnant, now online

 The New Yorker writes about prenuptial agreements that can be written online, and not just for the wealthy.

Why Millennials Love Prenups
Long the province of the ultra-wealthy, prenuptial agreements are being embraced by young people—including many who don’t have all that much to divvy up.
By Jennifer Wilson

"The past few years have seen the rise of new apps such as HelloPrenup, Wenup, and Neptune that fast-track the process; the latter has couples discuss their finances with an A.I. chatbot before being matched, by algorithm, with a lawyer.

...

"There had been limited cases since the eighteenth century in which prenuptial contracts were recognized in the U.S., but these typically pertained to the handling of a spouse’s assets after death. The idea of a contract made in anticipation of divorce was considered morally repugnant. In an oft-cited case from 1940, a Michigan judge refused to uphold a prenup, emphasizing that marriage was “not merely a private contract between the parties.” You could not personalize it any more than you could traffic laws."
 

Four international kidney exchange programs: 3 achieve substantial success

 Here's a paper reporting on the experience of four cross-border kidney exchange programs, whose experience teaches an important lesson.  In particular (see the figure below), one of  the programs is run by Spain, Italy and Portugal, whose  total population of approximately 118 million people is far larger than the combined population of the other three*, but manages to do less than 5% of the total cross-border exchanges, far fewer than any of the others.  Despite its size, the Spain-Italy-Portugal program only tries to match hard-to-match patient-donor pairs with other hard-to-match pairs, unlike the other three programs.

 International Kidney Paired Donation Programs: Evolution and Practices of 4 Large Collaborations
Klimentova, Xenia PhD1; Domínguez-Gil, Beatriz MD, PhD2; Viana, Ana PhD1,3; Manlove, David PhD4; Andersson, Tommy PhD5; Ashkenazi, Tamar RN, PhD6; Berlakovich, Gabriela MD7; Böhmig, Georg A. MD8; Burton, Jo RN, PGDip9; Coll, Elisabeth MD, PhD2; Dittmer, Ian FRACP9; Fiaschetti, Pamela MD10; Fronek, Jiri MD, PhD11; Hughes, Peter D. MBBS, PhD12,13; Ivo da Silva, Margarida MD14; Mor, Eytan MD15; Viklický, Ondřej MD, PhD16; Weinreich, Ilse Duus BMLS17; Ferrari, Paolo MD, FRACP18,19
Transplantation ():10.1097/TP.0000000000005602, December 24, 2025. | DOI: 10.1097/TP.0000000000005602

"Plain Language Summary: Kidney paired donation (KPD) programs are organized in various countries to facilitate the donation of kidneys from willing but incompatible donors by matching them with pairs in similar situations. These programs often struggle with an accumulation of difficult-to-match recipients and small pools of incompatible pairs. To address this, several international collaborations have emerged to expand the pool sizes and increase the number of transplants by “exchanging” donors’ kidneys across countries. We identified 4 established international KPD programs, each supported by protocols and agreements signed by the participating parties. Each program is presented separately, detailing its historical establishment, operational aspects, and statistics on pool characteristics and performance. Following this, we provide a comparative analysis of key aspects across the 4 programs. Each program has its unique context and specificities. Even though 3 of 4 collaborations started just before the COVID-19 pandemic, they have collectively facilitated >450 transplants. This underscores the importance of further developing these collaborations to share practices and experiences, and to facilitate more transplants, particularly for difficult-to-match recipients. Three of the 4 presented collaborations are either fully operated or led by European countries. This highlights the crucial role of ongoing international cooperation in the development of KPDs, in particular in Europe. By further promoting collaboration among countries, we can facilitate pan-European exchanges and improve access to live kidney transplants for patients in need.

 ...

"A fundamental difference between the programs is their collaboration model. STEP, ANZKX, and the Czech-Austrian-Israeli collaboration operate as “merged pool” model, where all participating pairs are combined for joint matching runs. For STEP and ANZKX, no other matching runs are conducted by partners at any level (hospital or national), whereas in the Czech-Austrian-Israeli collaboration, the Austrian and Israeli partners report performing local exchanges whenever compatible pairs are identified.
 

"In contrast, KEPSAT uses a “sequential pool” model, where national matches are attempted first, and only unmatched pairs are entered into the international pool. It is recognized that the last 2 strategy strategies may lead to a fragmented market, potentially limiting matches for highly sensitized patients, as easier-to-match pairs are removed beforehand."

 It's ironic that a program that appears to be intended primarily to help hard-to-match pairs is organized in a way that limits them in this way.

The paper concludes on an optimistic note (with which I fully agree):

"In conclusion, ongoing international cooperation is essential for advancing KPD programs globally. Expanding cross-border exchanges and improving access to kidney transplants can greatly benefit patients worldwide. Additional strategies, such as NDADs, desensitization protocols, and the inclusion of compatible pairs, can further enhance the effectiveness of both national and international programs. Oversight of these initiatives is crucial to safeguarding the welfare of both donors and recipients, as well as to maximizing the success rates of kidney transplants.
 

"Looking ahead, new initiatives, and projects, funded by international health organizations, such as the European Kidney Paired Exchange Programme project (https://www.hnbts.hu/euro-kep/project), funded by EU4Health and starting in November 2024, aim to expand global collaboration among KPD programs, building on and strengthening existing partnerships. This increased international cooperation is expected to create additional opportunities for patients in need of kidney transplants worldwide, making life-saving transplants accessible to more individuals regardless of their geographic location."

 ########

Earlier: Portuguese transplant docs noted the problem and argued for more global kidney exchange:

Tuesday, March 12, 2024 Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 ######### 

*Notes on population:

Spain: 49 million; Italy 59 million; Portugal 10 million ; KEPSAT total pop =  approx 118 million

 Australia 28 million; NZ 5 million: ANZKX total pop approx 33 million

Austria: 9 million, Czech Republic  11 million, Israel 10 million: AT-CZ-IL total 30 million

Sweden: 11 million; Norway:  6 million; Denmark 6 million; Finland  6 million: STEP total approx 29 mil

Should more professional societies condemn some of their members?

 Robert Reich posed the question on his substack:

Ethics Shmethics
Why are America’s most powerful professional associations silent in the face of professional disgraces in the Trump regime?
Robert Reich 

"Hell, if the American Economic Association can permanently ban Harvard economist (and former treasury secretary) Larry Summers for conduct “fundamentally inconsistent with its standards of professional integrity” (Summers had repeatedly asked Jeffrey Epstein for advice on Summers’s pursuit of a younger economist), surely the American Bar Association should ban Lindsey Halligan, and the American Medical Association, Vinay Prasad.

"Where are the American Bar Association and the American Medical Association during Trump’s unscrupulous reign? " 

UNOS continues to run the deceased-donor organ allocation system

 The U.S. Health Resources & Services Administration (HRSA) has published a document outlining its progress in modernizing the Organ Procurement and Transplant Network (OPTN) as required by recent legislation.  The idea was to make the system less dependent on the United Network for Organ Sharing (UNOS), which had been the single federal contractor running the OPTN since its inception.  For the time being, at least, it appears that UNOS will continue to run the organ allocation system.

 Modernizing the Nation’s Organ Donation, Procurement, and Transplantation System

"For more than 35 years, the OPTN was operated through a single national contract.  

"While this structure supported growth in organ donation, procurement and transplantation, the increasing complexity of modern medicine and the demands of real-time technology, safety, data, and public accountability required a new approach.  

"The bipartisan 2023 Securing the U.S. Organ Procurement and Transplant Network Act gave a clear mandate: bring the OPTN into the modern era of governance, technology, and healthcare delivery". 

 

 

Happier new year!

 Things I'm looking forward to in 2026 (not in chronological order)

U.S. midterm elections (forthcoming Nov 3, but you can start contributing/worrying now).

Publication of my new book, Moral Economics (forthcoming May 12, but you can preorder now:)

Grandchildren growing exuberantly older.

Their grandparents growing gently older (while their parents remain unchanged amidst the storm). 

The year in passings

 It's been a long year in many ways.  Here are the partings noted on this blog:

Sunday, December 21, 2025 Michel Callon (1945–2025): A life with passion for economies, in J. of Cultural Economy

     Saturday, August 30, 2025 Michel Callon (1945-2025)

Friday, December 12, 2025 Kate Ho (1972-2025)

Sunday, December 7, 2025 Tom Stoppard (1937 –2025)

Friday, December 5, 2025 Ludwig Amadeus Minelli (1932 – 2025), leader of Dignitas assisted suicide organization 

Thursday, December 4, 2025 Scientists and policy makers with feet of clay [James Watson (1928-2025)]

Monday, November 3, 2025 David Gale (1921-2008) remembered, with a (belated) 100th birthday volume

Sunday, October 12, 2025 John Gurdon (1933-2025)

Saturday, October 4, 2025 Jane Goodall (1934-2025)

 Thursday, July 3, 2025 Workshop in Memory of YingHua He, July 7-8

Tuesday, April 29, 2025 National Academy of Sciences Elects Members and International Members (Ed Leamer)

Wednesday, April 16, 2025 Pat Bajari (1969-2025)

Tuesday, April 15, 2025 Danny Kahneman's last interview, and its backstory

Saturday, March 15, 2025 Danny Kahneman's final decision

Friday, February 28, 2025 Kevin Sontheimer (1938-2025)

Tuesday, February 25, 2025 Donald Shoup (1938-2025) led the war on (too much) free parking

Monday, February 3, 2025 Civil service in the United States, RIP (1883-2025)

Monday, January 27, 2025 Derek Humphry, Pivotal Figure in Right-to-Die Movement, (1930-2025) 

Thursday, January 2, 2025 Diane Coleman, Fierce Foe of the Right-to-Die Movement, (1953-2024)  

Taxation as a disincentive to contraception in China

 The PRC believes in economic incentives and disincentives. (But they also have other arrows in their quiver...)

China to hike tax on condoms in attempt to boost falling birth rate.  From 1 January, contraceptives will be subject to a 13% VAT rate – part of a carrot-and-stick approach by the government to increase births.  by Amy Hawkins  

"China is set to impose a value-added tax (VAT) on condoms and other contraceptives for the first time in three decades, as the country tries to boost its birthrate and modernise its tax laws.

"From 1 January, condoms and contraceptives will be subject to a 13% VAT rate – a tax from which the goods have been exempt since China introduced nationwide VAT in 1993.
...
After imposing a strict one-child policy for more than 30 years, China has over the past decade been introducing a suite of “carrots” to induce people to have more children in a bid to boost the falling birthrate.

As well as raising the limit on the number of children permitted per couple to three, provinces have been experimenting with offering discounts on IVF treatment and cash subsidies for extra children. Some local governments offer newlyweds extra days of paid leave to encourage people to tie the knot.

But the fact that condoms and contraceptives look set to become more expensive has been met with ridicule on social media. “What is wrong with modern society? They are truly going to extreme lengths just to make us have children,” wrote one user on Weibo. 

...

"This year, the government also allocated 90bn yuan ($12.7bn) for its first nationwide childcare subsidy programme, offering 3,600 yuan annually for each child aged under three. And on Saturday it announced plans to expand its national healthcare insurance programme to cover all childbirth related expenses.

"But incentives have had little effect. In 2024, the birthrate was 6.77 per 1,000 people, a slight increase on 2023, but still far below historical levels. A rising death rate caused by an ageing population means China’s population has been shrinking for at least three years.

"Now there are concerns authorities may be turning to “sticks” to achieve the national policy goal of more babies.

Women in some areas have reported receiving phone calls from local government officers asking about their menstrual cycles and childbearing plans. In December, Chinese media reported that women in a county in south-west China’s Yunnan province were being required to report the date of their last period to the local authorities." 

Medicare funding of medical residencies

 I'm always puzzled by the fact that much of the discussion of the wages of medical residents ignores that many residency positions are paid at rates established by Medicare, which also has a big influence on the number of residency positions.

MedpageToday has the story: 

CMS Funds 400 New Residency Slots — Most new Medicare-funded positions will go to primary care, psychiatry programs by Joedy McCreary 

"The Centers for Medicare & Medicaid Services (CMS) last week allocated the 400 Medicare-funded residency slots to 135 hospitals in 37 states. Nearly two-thirds of the positions will support primary care and psychiatry residency programs.

...

"The announcement "marks a critical milestone in enabling academic health systems and teaching hospitals to continue providing top-quality patient care," said Jonathan Jaffery, MD, the AAMC's chief healthcare officer. "Academic health systems are already incurring a significant financial burden by choosing to train a portion of their medical residents without federal support. This new round of residency positions will allow them to continue investing in physician training to the benefit of patients nationwide." 

...

"Under the Consolidated Appropriations Act of 2021, Congress authorized 1,000 new residency positions to be distributed over 5 years. The 200 positions announced this month represent the fourth allocation from that total. An additional 200 slots were authorized under the Consolidated Appropriations Act of 2023, with at least 100 positions required to support psychiatry or psychiatry subspecialty residency training programs.

"The Balanced Budget Act of 1997 capped the number of Medicare-supported residency positions at each teaching hospital. Lifting that cap, the AAMC's 2024 report concluded, would help alleviate -- though not fully eliminate -- current and projected physician shortages. "

#######

On a lighter note, here's  their headline about Xmas-time emergency medicine:

Deck the Halls With Ow's From Folly: What the Numbers Tell Us About Holiday Injuries

 

A rare -directed- deceased donor kidney transplant

 Most organ transplants come from deceased donors, and the vast majority of these deceased donor organs are allocated by a regulated system of national waiting lists. That is, the organs of a deceased donor go to strangers in need. In contrast, most transplants from living donors (of kidneys and livers) are direct donations from someone healthy enough to donate to someone who they know.*  Living donations are also different in that they can be planned well in advance, while deceased donations have to be hastily arranged following a death.

But it is legal, and sometimes possible, for the next of kin of a deceased potential donor to direct an organ donation to someone they know who needs a transplant.  This will only take place if the potential recipient is available on short notice, and if the donor organ is compatible with the recipient.  So it's a rare event: the next of kin need to know someone in need, and the transplant has to turn out to be feasible.

But rare events happen, and the NYT reports on just such a story:

A Man Who Shunned Cheap Sentiment Left a Gift for Others: Life  By Dan Barry

"Informed that her 55-year-old brother would never regain consciousness, Darlene Costello made the heartbreaking decision to have him removed from his ventilator — only to learn, seconds before it was time, that Brendan was a registered organ donor.

"Once Ms. Costello calmed down — why wasn’t this known before? — she came to embrace the news of her brother’s final selfless act. She also knew someone who desperately needed a kidney. Calls were made, tests done, overwhelming odds overcome."

...

" His lungs went to a woman in Tennessee, his right kidney to a man in Pennsylvania. And his left kidney was received by Ms. Costello’s mentor and employer, Dr. Sylvio Burcescu, 62, whose ability to run his Westchester County clinic had been hampered by a rare kidney disease requiring dialysis."

########

*Nondirected living donors can also start chains of kidney exchange. 

NKR in the NYT

 Today's NYT has a story on the country's largest kidney exchange network, a private company with opaque finances called National Kidney Registry (NKR). The story also raises questions about some of the promises NKR makes through a voucher program.

 How One Father Created an Organ Empire.  The National Kidney Registry has matched thousands of kidney donors with recipients. It has also paid millions of dollars to a company owned by its founder.    By  Danielle Ivory, Grace Ashford and Robert Gebeloff 

 "Since its founding, N.K.R. has enabled nearly 12,000 such swaps, called paired donations, far more than any other public or private program. The organization’s focus on technology and efficiency has jolted a sluggish system, many health experts said.

But at the same time, N.K.R. has created a multimillion-dollar business with considerable power over the flow of thousands of organs, according to interviews with more than 100 people in transplant medicine and a review of business records. Many doctors told The Times the stakes of these lifesaving exchanges were too high to be managed by a private company with little government oversight.

...

"The organization was a nonprofit for more than a decade, but during that period paid at least $39 million for technology and other services to a company owned by Mr. Hil, charity filings show. In 2023, N.K.R.’s commercial operations were sold to a new for-profit company owned by Mr. Hil, making its finances much more opaque. 

...

“It’s basically a money transfer,” said Dr. Lloyd Ratner, a surgeon at Columbia University who performed the second-ever paired transplant in the country. He said the hospital had parted ways with N.K.R.

...

"One of N.K.R.’s most innovative policies, many doctors said, is known as voucher donation: Donors can choose to give their kidneys immediately, in exchange for organ vouchers their loved ones redeem later.

"This arrangement has helped N.K.R. expand its pool. But vouchers add risk for donors giving on behalf of hard-to-match patients. They might go through surgery months or even years before their loved ones get a match. Matches are especially unlikely, doctors said, for “very highly sensitized” patients who carry antibodies likely to reject a transplant.

...

" Doctors told The Times that they knew of some patients who became too sick or died before they redeemed their vouchers."

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Not mentioned in the article is the Alliance for Paired Kidney Donation (APKD) a smaller, older, highly ethical non-profit kidney exchange network founded by the transplant surgeon Mike Rees (with whom I often work). 

Medical aid in dying to become available in New York State

 Here's the announcements from the New York State Governor's office:

Governor Hochul Reaches Agreement With State Legislature to Pass Medical Aid in Dying Act in New York  

"Governor Hochul today announced an agreement with the Legislature to make medical aid in dying available to terminally ill New Yorkers with less than six months to live. This comes after careful reflection and deliberation with the bill’s sponsors, advocacy organizations, and most importantly, everyday New Yorkers who shared personal experiences with the Governor. The bill, with the agreed-upon amendments, will be passed and signed in January, and the law will go into effect six months later.

“New York has long been a beacon of freedom, and now it is time we extend that freedom to terminally ill New Yorkers who want the right to die comfortably and on their own terms,” said Governor Hochul. “My mother died of ALS, and I am all too familiar with the pain of seeing someone you love suffer and being powerless to stop it. Although this was an incredibly difficult decision, I ultimately determined that with the additional guardrails agreed upon with the legislature, this bill would allow New Yorkers to suffer less–to shorten not their lives, but their deaths.”
 

"The bill, as passed by the Legislature, had a number of protections in place to ensure that no patient was coerced into utilizing medical aid in dying and no doctor or religiously affiliated health facility was forced to offer medical aid in dying. With today’s agreement, the Governor announces a number of additional guardrails that the Legislature has agreed to enact aimed at ensuring the integrity of the patient’s decision and the preparedness of medical institutions to appropriately administer medical aid in dying. Today’s agreement memorializes a shared path forward on this bill, with additional key guardrails, including:

    A mandatory waiting period of 5 days between when a prescription is written and filled.
    An oral request by the patient for medical aid in dying must be recorded by video or audio.
    A mandatory mental health evaluation of the patient seeking medical aid in dying by a psychologist or psychiatrist.
    A prohibition against anyone who may benefit financially from the death of a patient from being eligible to serve as a witness to the oral request or an interpreter for the patient.
    Limiting the availability of medical aid in dying to New York residents.
    Requiring that the initial evaluation of a patient by a physician be in person.
    Allowing religiously-oriented home hospice providers to opt out of offering medical aid in dying.
    Ensuring that a violation of the law is defined as professional misconduct under the Education Law.
    Extending the effective date of the bill to six months after signing to allow the Department of Health to put into place regulations required to implement the law while also ensuring that health care facilities can properly prepare and train staff for compliance."